=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780717744
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REM INDIANA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 04/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1406 W TARKINGTON DR
-----------------------------------------------------
City | GREENSBURG
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47240-6240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-662-8626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9000 KEYSTONE XING STE 200
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46240-2148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-581-2380
-----------------------------------------------------
Fax | 317-581-2378
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | BRETT IAN COHEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 800-388-5150
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number | 2524M0046JN04
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------